Objective: To identify risk factors for level II and level IV lymph node metastasis in papillary thyroid carcinoma (PTC) and to evaluate the predictive value of different tumor location classification methods. Methods: A retrospective analysis was performed on PTC patients who underwent thyroid surgery between January 2022 and May 2025. Clinical and pathological variables were collected. Tumor location was classified using the conventional longitudinal trisection method and a middle thyroid vein–based method on preoperative contrast-enhanced CT images. Univariate analysis and receiver operating characteristic (ROC) curve analysis were used. Results: Among 152 patients, 59 (38.82%) had level II lymph node metastasis and 113 (73.34%) had level IV lymph node metastasis. Tumor location was significantly associated with metastasis in both levels (P < 0.05). The middle thyroid vein–based classification showed better predictive performance for level II metastasis (AUC = 0.749) than the conventional method (AUC = 0.608), and slightly higher accuracy for level IV metastasis (AUC = 0.687 vs. 0.650). Conclusion: Tumor location is closely associated with level II and level IV lymph node metastasis in PTC. The middle thyroid vein–based classification may improve preoperative risk assessment of lateral cervical lymph node metastasis.